Fill and Sign the Georgia Disclaimer Form

RENUNCIATION AND RIGHT TO DISCLAIM PROPERTY IN THE __________________ COURT OF __________________ COUNTY STATE OF GEORGIA In Re the Estate of ) Civil Action No. __________________ ________________________ ) Name of the Deceased ) ) ) ) ____________________________________________________________________________ I. Pursuant to the Georgia Code Title 53, Chap. 1, Art. 3, the undersigned, _________________ , chooses to exercise his/her right to disclaim ( ) a partial interest or ( ) the entire interest in the described property. II. The undersigned has an interest in the property in the above-captioned estate of __________________ (decedent) who di ed on _______________________ , 20 ______ . III. The undersigned attests that the disclaimer of the property interest will be filed no later than nine months after the death of the decedent. IV. Pursuant to the provisions of paragraph _____ of decedent's last will and testament dated _______________________ , 20 ______ (the "Will"), _______________________ is entitled to receive the following property: ____________________________________________________________ V. Pursuant to applicable law of the State of Georgia, and the Internal Revenue Code of 1986, if applicable, the undersigned hereby renounces and disclaims any interest or right to the property or asset of the deceased described in paragraph IV. VI. The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. VII. This renunciation and disclaimer shall for all purposes be deemed to relate back to the date of decedent's death and is an irrevocable refusal to accept that property effected hereby, and is hereby delivered to the personal representative, executor or executrix of the Estate of _______________________ to be filed with the court in the above-captioned proceeding. DATED this ______ day of __________________ , 20 ______ . _________________________ (Name) Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this ______ day of __________________ , 20 ______ . _______________________________ (Name) _______________________ Personal Representative/Executor/Executrix Signed, sealed, and delivered in the presence of: ______________________________ ___________________________ (Seal) Witness Print Name ______________________________ ___________________________ (Seal) Notary Public Print Name (Seal) ___________________________ (Seal) I certify that on __________________ , 20 ______ , I delivered a true copy of the Renunciation and Disclaimer of Property by ( ) personal delivery, ( ) registered mail, and/or ( ) certified mail, return receipt requested, to the personal representative/executor/executrix or other fiduciary of the decedent. DATED this ______ day of __________________ , 20 ______ . _________________________________ Signature _______________________________ Print Name _______________________________ Address _______________________________ City, State, Zip Code _______________________________ Telephone